24 May 2011

So there's this Twitter machine, which you might have heard of. It's all the rage among the kids these days. Doctors have adopted it too, and as happened in the blogosphere there are no shortage of self-righteous, self-appointed internet scolds out there to police our conversations and make sure we all stay in line with their view of how doctors should comport themselves. The most recent is Dr Bryan Vartabedian, who blogs at 33charts and tweets at @Doctor_V. He chose yesterday to attack an anesthesiologist over a middle-of-the-night exchange about a patient with a priapism: Unprofessional Physician Behavior on Twitter

Now, I'm not averse to picking a fight or using strong language on the internet. Nor am I averse to calling someone out by name. You need to be able to handle criticism on the internet. But a couple of things struck me on this.

First, the tone: I have been attacked relentlessly on the internet and I've never hesitated to respond in kind. I took out a little frustration on DrRich the other day, and maybe that was a little over the top, but he's a guy who himself engages in hyperbolic language so I don't feel too bad about it. But It's, well, it's just rude to come out and lay into someone who is generally nice and inoffensive. Not only is it rude, it's self-defeating. You could initiate a conversation and have a teachable moment. But when your headline contains the word "Unprofessional" it takes the teachable moment and makes it an adversarial encounter.

Isn't that convenient, as well as self-righteous? I understand that DrV has a principled issue with anonymity on the net among medicos. Fair enough. Don't link to them or endorse them. But are the anonymous health care provders some sort of unspeakable unpeople to be shunned? Especially when you are willing to call them out publically? Frankly, it's a jerk move to do so while maintaining that it's beneath you to correspond with him or her.

Then you have the actual substance of the complaint. DrV's central complaint was that there was a little giggle about the nature of the patient's medical condition. I take it that DrV has never read this blog, which at times has been a celebration of the strange mishaps, maladies and sexual proclivities of our fellow human beings. I'm sure his head would explode at these posts. For my part, I try to remain non-judgemental, educational when possible, and respectful, though it's impossible to ignore the very real humor in some cases. Some of my fellow bloggers, and I'll prove myself better than DrV by not pointing fingers, are real assholes with nothing but scorn, contempt, anger and disdain for their patients. They are truly a disgrace to the profession. So if you are looking for physician behavior on the internet which you want to shame and label as "unprofessional," DrV picked a fairly weak case, I think. And if you're going to pick a fight, you really need to have a clear, cut and dried example of behavior which crosses a bright line, which was most definitely not the case in the incident thread.

It's more arrogant, I think, for DrV to impose his personal value system on behavior for which there is not a consensus within the medical community. We all agree that HIPAA is a minimum standard, and that there is a moral obligation to be more protective towards patient privacy than the law's bare requirement. There's a lot of diversity of opinion, however, on where the line is. While DrV asserts that simply "disclosing the details of a case" is unprofessional, if you look at the actual conversation nothing more was disclosed beyond the diagnosis, lack of risk factors, and the duration of symptoms. That's hardly a lot of detail. I should also pont out that she expresses significant empathy for the patient which is to her credit.

The real issue here is that as a profession we are grappling with how to take the conversations that go on between healthcare providers and adapt to the internet. If this were a private exchange at the nursing station, or at a cocktail party, it would not raise an eyebrow. In the public arena, though, the boundaries are less clear. DrV is clearly an absolutist in his view of the amount of patient information that providers can discuss publicly - zero. He's entitled to his opinion, but clearly a large number of doctors and nurses disagree. I think it is OK to discuss patients so long as it is clearly anonymous, respectful and has some redeeming value. The value may be educational, or it may be in telling a human story. It may be to express a strong emotion that a healthcare provider feels, be it anger, shame, humor, satisfaction, etc. It may just be because the provider wants to tell his or her story. Just because we are doctors does not mean we cannot share our experiences. I took an oath of confidentiality, not silence. I would also point out that every single medical journal has sections in which doctors express their human feelings and experiences. The internet is no different, just self-regulated.

I think we all agree that the internet and social media is a new ecosystem for health care professionals, and that there are landmines which incautious physicians can step on. I think we agree that patients' identities and dignity must be protected. There's more common ground here than disagreement. To DrV, I would suggest that his version of appropriate physician behavior is not universally accepted, and he creates more heat than light by insulting well-meaning and inoffensive physicians.

19 comments:

I don't discuss patients online- ever. But then I don't encourage health professionals or students to start using Twitter either. I'm here to learn about all sorts of things and how people make decisions about how to 'be' online is one of them.

You get down on Dr. V about his attack of this Twitter exchange, but then rip other bloggers for "attacking" you despite your kind, loving, undyingly liberal and perfect demeanor wrought with nothing but lemon pie and a smile when the thing you write about most is LIBERAL POLITICS?

The point was that rich and I are both kinda jerks, at least we both have a tendency to pick fights. I can throw a punch and I can take a punch, and I don't get angst about mixing it up with someone who's like minded.

But mommydoc is not a arguer and didn't deserve to get bitch-slapped for something that ranks about a one-point-five on the scale of Internet Provocations. That's all.

BRAVO! A post that long needed writing. While I do not always agree with the joking around and other things, I have long been bothered by the fact that narrative blogging seems to be on the "out" with those who are either revered, consider themselves revered, or are "rising" to be revered. It is abhorrent that they claim that their way of blogging is the only way. When medblogging was at its most popular a few years ago, the blogs that were the most interesting to read were always ones that took a more narrative approach. Maybe they didn't do so with every post, but I always enjoyed reading these narrative commentaries. Now, narrative is considered unprofessional by many and apparently has no place. Narrative is what made blogging popular. It leveled the playing field between clinicians and patients. It helped to show that providers were more human.

I didn't like all of those who blogged narratively. Similar to what you describe about colleagues who wrote with scorn, etc - I was attacked by at least one ER physician (who I think blogged anonymously) who frequently wrote in this way about patients. To this day I refuse to read blogs of that nature. If they hate patients and health care so much, then they should find another profession.

But stories are what make us human. Someday, blogging, twitter, and facebook will all be distant memories. Stories will not.

I'm not interested in reading a blog that glorifies social media as the next big thing. Blogs that talk about social media and the rules that others should follow on it are very circular. Social media, in its truest form of "social" networking, will NEVER have a place in true, private, health care interactions. You can use it to make educational statements and link things you find reputable, but I do not believe social media holds the key to the future of health care - and especially not by continuously using social media to write about social media. If used to share narratives and links to information, however, I believe that's a different story.

Stories and narrative make a world of difference. When I did blog narratively, my posts were frequently commented on by former NICU parents who loved and appreciated what I wrote. In blogging about my own experiences as a patient, I met others who were looking to connect with patients who experienced some of the same things they did. It helped ease the pain of a system that has become cold and uncaring in many ways. I found the human side of health care (which I strive to practice daily) in blogging.

The fact that even patients are warned against posting their medical narratives is sad to me. While I agree that patients should be careful about some of the things they say, I still think that the stories of our experiences are ours to tell. If we choose to do so, then so be it. The new rules of social media blogging have widened the gap between providers and patients as opposed to narrowing it.

I agree. Dr V should chill out and be quiet. Or not. He can say what he wants I guess but that woman certainly did not deserve to be bitch slapped. Now, when you say you get attacked for your political posts, I say you ask for it - just like I do if I post a political rant. I try not to post too many of them since I don't relish regular on-line ongoing arguments. This mommydoc commenter was clearly not looking to pick a fight - and I think that's your point, those who pick them (you and Dr Rich for example), can expect them, those who don't, shouldn't get attacked.

The real problem/issue here is that there are two types of medical bloggers:

1. Those that really want to be print media-style journalists who get hired to write about a medical generality or to give an opinion about a bill coming before the Senate. Kevin, MD is the obvious example. "I write a blog, but my blog isn't that much different than something that you'd find in a magazine or newspaper."

2. Those that love to write and entertain people with their stories/experiences, whatever those stories may be.

The #1s can't really figure out the #2s. #1 is the stodgy academic who is concerned about his "online image" and appearing kind and compassionate or an expert to the public. #2 is your "fun uncle" that holds "slider-eating" contests with you and your cousins, gives the winner a sword, and tells you about the time he robbed a bank in gory details*.

* = Yes, I have an uncle who robbed a bank and he is, in fact, quite fun to hang around.

The #1s are boring. Sorry. I have plenty of Emerg Nurses Association journals sitting in a pile that I can go through if I want to hang with the #1s for awhile.

If you accept that mommydoctor has a established online identity, the fact that she was publicly made an example of and shamed does do lasting damage to her reputation. Sure, she could ditch it and start over, but an online identity represents a significant investment.

Moreover, the person behind the ID has just had a rough day - beyond what is deserved based on the "offense". I bet she *feels* bitchslapped.

And yes, we are online friends, which certainly raised my ire. That may have been why I was moved to respond, but did not drive what I had to say.

meh. this DrV is nothing but a thin-skinned internet shmuck who needs to grow a sense of humor and did not deserve 1/10 of the comments he got on that post, let alone such a well crafted response from you.

he might keel over and die if he reads the likes of panda bear, medschoolhell, or m.d.o.d.

Dr. V wrings his hands over the supposed privacy violation of the patient but doesn't see any issue leaving @mommy_doctor's Twitter handle in the clear when bemoaning the horrors of unprofessionalism. I call bullshit. If this was a simple matter of ethics & professionalism, he'd have taken the 5 seconds necessary to depersonalize the example tweets and keep the conversation on the behavior, not the person. But he didn't. A veritable champion of privacy and dignity, he.

I read reactions before V's original post, both positive & negative. Having followed @mommy_doctor for a month or three, and reading and rereading the excerpted tweets, I still am baffled at the brouhaha. Admittedly, I'm a layman but I just don't see it. I'm missing her lack of compassion for the patient and the 'obvious' HIPPA violation (something Dr. V doesn't directly accuse @mommy_doctor of but makes sure to egg on all his sycophants to look into.)

I don't take HIPPA lightly; I've worked under its educational counterpart (FERPA) and I'd be on @mommy_doctor if she crossed an obvious line. She talked about a case of someone with a condition that 12-year-olds titter about; we don't know time, place, age, race - anything beyond the guy had a functional penis and no risk factors. Big goddamn deal.

I don't often agree with Nurse K but IMHO she nails it with the #1/#2 example. Dr. V seems to want everyone to adhere to his unarticulated definition of professionalism ("be more like me") and will happily throw you to the wolves if you don't. Especially if you're a girl.

Note there's no sense of reflection on Dr. V's part, no place in his post or his follow-up comments where he might entertain the notion he might be wrong. I think that's telling. Maybe I'm wrong, but Dr. V seems less interested in a debate and more interested in being a dick.

Dr V is a giant concern troll, who whipped up the "oh noez!11!!!" finger pointing for his own gain. If he was truly concerned about the moral/ethical implications of the posts he could have gone about his argument in a more constructive manner. Instead, he decided to sound the interweb klaxon, calling @mommy_doctor out, and igniting the flame wars. Also, he prodded his audience on with the "what do you think" "decide for yourself" blah blah.

This is the sort of behavior I'd expect to see on 4chan, or in a MMORPG like World of Warcraft, not on the blog of a "professional" physician like Dr V. Then again, this is the internet, and it's serious business...

I think her tweet was far from unprofessional, and that Dr.V's statesments were self-righteous at the very least. Finding humor in medical situations is a coping mechanism.Call it morbid, call it odd, heck you can call it unprofessional if you want. But sometimes you have to laugh or else you will cry. When you hold the balance of life and death in your hands, you have to find a way to lighten the mood and deal with the difficulties of your profession.Honestly, penises are hilarious. The very thought of priapism is funny. And if I can't be a healthcare provider and also have a sense of humor, then I suppose I need to hang up my stethoscope and go on a stand up tour. I choose laughter, love, and happiness over cold hard medicine. Patients need laughter and joy. So do we. And I'll say it again, Priapism is funny, I don't care who you are.

After thinking this whole incident over for a couple of days, I came to see your side as well. There was an #MDchat on Twitter on 5/24 and it was so one-sided against mommydoc that afterwards it didn't sit right in my gut. The intent of the discussion was not about blaming any single person, but you know how internet can bring about mob mentality. Time and again it's a reminder that different rules (and precautions) apply to online discussions than in the locker room.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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